Microsoft word - travel questionnaire.docx

The Green House Surgery Travel Questionnaire
Personal details
Consent to contact you by SMS (text) message or Dates of trip
Itinerary and purpose of visit
Please tick as appropriate below to best describe your trip
Personal medical history
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions) Do you have any allergies for example to eggs, anitibiotics, nuts? Have you ever had a serious reaction to a vaccine given to you before? Does having an injection make you feel faint? Do you or any close family members have epilepsy? Do you have any history or mental illness including depression or anxiety? Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Women Only: Are you pregnant or planning pregnancy or breastfeeding?
Have you taken out travel insurance and, if you have a medical condition, informed the insurance company about this? Please write below any further information which may be relevant Vaccination history
Have you ever had any of the following vaccinations/malaria tablets and if so when?
Tetanus
For discussion when risk assessment is performed within your appointment: I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given. FOR OFFICIAL USE
Patient Name:
Travel risk assessment performed Yes ( ) No ( )
Travel vaccines recommended for this trip
Disease protection
Travel advice and leaflets given as per travel protocol
Malaria prevention advice and malaria chemoprophylaxis
Chloroquine and proguanil
Further
information
General Information for Travellers
The remit of NaTHNaC is ‘to protect the health of British travellers’. That is why we strongly encourage travellers to discuss their travel plans with their GP, practice nurse or It is during this discussion that hazards specific to your destination can be identified, and Why do I need to go for pre travel health advice?
A pre travel consultation does not just involve injections. In fact the majority of hazards faced by travellers abroad are not prevented by vaccines. The pre travel consultation will identify these hazards and provide you with the opportunity to discuss how these risks The benefits of a pre travel consultation are Up to date verbal and written advice on a range of travel health issues Information about recent disease outbreaks Travel health vaccinations, malaria tablets and other medications
Which travellers should go for a pre travel consultation? Anyone planning a trip outside of Western Europe, the States, Canada, Australia and New Zealand, should discuss their travel plans with a health professional. Generally the risk of infectious disease is greater in resource poor countries; however certain advice will be applicable to all travellers regardless of their destination. For example travellers to Mediterranean resorts should still protect themselves against insect bites, the damaging rays of the sun, and avoid risky behaviour. There are certain travellers in whom a pre travel consultation is particularly important, • Those with pre-existing medical conditions Travel advice for these individuals should be specifically tailored to their needs.
How long before I travel should I seek advice?
As a general rule, 6-8 weeks prior to travel will give ample time for all necessary For those planning longer trips into remote areas, courses of vaccines may be recommended which can take several weeks to complete. It is still worth seeking health advice even at the last minute, as there are some vaccines that can be given at short notice, it is always worth taking malaria tablets for last minute travel, and travellers will benefit from the preventative advice. What can I expect at the pre travel consultation?
The nurse or doctor will want to make a “risk assessment.” This will identify hazards related to your destination and planned activities, and will provide you with individualised advice. In order to make a risk assessment you will be asked, during your first visit, for detailed information regarding you and your trip. For example This process can appear excessive, but is vital in order to tailor the advice to your Following the risk assessment, the nurse or doctor will make recommendations on vaccines and malaria tablets that may be appropriate, as well as offer advice on other Where can I go for travel health advice?
Many GP surgeries operate a travel clinic, usually run by the practice nurse. Try to allow plenty of time to make an appointment, as surgeries are often very busy. Alternatively, there are many specialist travel clinics around the country; these usually operate on a private basis. Unfortunately, NaTHNaC are unable to provide travel advice directly to the public; however advice can be sought from the following telephone advice lines for the public • Hospital for Tropical Diseases - 09061 337733 (Calls cost 50p per minute; calls from mobiles and some networks may be higher) • Liverpool School of Tropical Medicine - 0906 701 0095 (Calls cost 50p per minute; calls from mobiles and some networks may be higher) • Malaria Reference Laboratory - 09065 508908 (Calls are charged at £1 per minute)

Source: http://www.thegreenhousesurgery.co.uk/docs/travel_questionnaire.pdf